Inspection Reports for Magnolia Manor Methodist Nsg C
2001 SOUTH LEE STREET, AMERICUS, GA, 31709
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 9, 2025, found no deficiencies, confirming correction of prior issues cited in March 2025. Earlier inspections showed a mixed pattern, with the March 14, 2025 survey identifying deficiencies related to resident evaluations after falls, mental health referrals, smoking safety assessments, and food safety practices. Complaint investigations were mostly unsubstantiated, though a substantiated complaint in February 2025 did not result in citations. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed recent deficiencies effectively, showing improvement in compliance over the latest inspection cycle.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
139 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 9, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the March 14, 2025, Standard Survey and to investigate Complaint Intake Number GA00254749.
Complaint Details
Complaint Intake Number GA00254749 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the March 14, 2025, Standard Survey were found to be corrected. The complaint GA00254749 was found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 9, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the March 14, 2025, Standard Survey and to investigate Complaint Intake Number GA00254749.
Complaint Details
Complaint Intake Number GA00254749 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the March 14, 2025, Standard Survey were found to be corrected. The complaint GA00254749 was found to be unsubstantiated.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 14, 2025
Visit Reason
An annual licensure survey was conducted at Magnolia Manor Methodist from March 11, 2025 to March 14, 2025.
Findings
There were no deficiencies cited during the annual licensure survey.
Inspection Report
Routine
Census: 139
Deficiencies: 4
Date: Mar 14, 2025
Visit Reason
A standard survey was conducted from March 11 through March 14, 2025, including investigation of Complaint Intake Number GA00254138, which was found unsubstantiated.
Complaint Details
Complaint Intake Number GA00254138 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Findings
The facility was found noncompliant with Medicare/Medicaid regulations, with deficiencies including failure to refer a resident for PASARR Level II evaluation, failure to provide timely medical evaluation after a resident's fall with head injury, failure to complete smoking safety assessments, and failure to maintain food safety and sanitary conditions in the dietary department.
Deficiencies (4)
Failed to refer resident with newly identified mental disorders for PASARR Level II evaluation.
Failed to ensure appropriate medical evaluation of resident after fall with head injury, resulting in actual harm and decline in abilities.
Failed to complete assessments to identify deficits in ability to smoke safely for a resident who smokes.
Failed to ensure food safety and sanitary conditions, including elevated freezer temperatures, thawed food stored improperly, cross contamination from improper pan cover sanitation, and failure to perform hand hygiene and use proper protective gear.
Report Facts
Residents present: 139
Residents sampled for falls: 37
Residents sampled for smoking: 3
Temperature readings: 20
Pieces of thawed chicken: 150
Medication hold days: 7
BIMS scores: 13
BIMS scores: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook LL | Cook | Observed improperly sanitizing pan covers and continuing meal service despite contamination risk |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding Resident #119's fall and medical decline; stated resident would likely be transferred to hospital but family declined |
| Administrator | Administrator | Interviewed regarding PASARR referral failure and Resident #119's care; acknowledged lack of referral and delayed CT scan |
| Social Worker | Social Worker | Noted Resident #119's cognitive decline and notified MDS nurse |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding freezer temperature issues and food safety concerns; failed to report freezer issues timely |
| Maintenance Director II | Maintenance Director | Reported notification and HVAC service call for freezer repair |
| MDS Coordinator | MDS Coordinator | Reported no smoking assessments completed for Resident #22 |
Inspection Report
Life Safety
Census: 140
Capacity: 238
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The Emergency Preparedness Program and Life Safety Code Survey for Magnolia Manor Methodist were found to be in compliance with all applicable federal regulations and NFPA standards.
Report Facts
Certified Beds: 238
Census: 140
Inspection Report
Abbreviated Survey
Census: 143
Deficiencies: 0
Date: Feb 10, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint intake number GA00253668.
Complaint Details
Complaint intake number GA00253668 was substantiated.
Findings
The complaint was substantiated, but no deficiencies were cited during the survey.
Report Facts
Facility census: 143
Inspection Report
Abbreviated Survey
Census: 130
Deficiencies: 0
Date: Apr 10, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00242653, initiated on February 29, 2024, and concluded on March 6, 2024, with a reopening and conclusion on April 10, 2024.
Complaint Details
Complaint number GA00242653 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited related to complaint GA00242653 during the investigation.
Inspection Report
Deficiencies: 0
Date: Jan 25, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Magnolia Manor Methodist Nursing Center following a state inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 120
Deficiencies: 0
Date: Jan 25, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the December 7, 2023 Recertification Survey.
Findings
All deficiencies cited in the December 7, 2023 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
A Life Safety Code Follow-up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited tags have been corrected as noted during the follow-up survey.
Inspection Report
Annual Inspection
Census: 124
Deficiencies: 3
Date: Dec 7, 2023
Visit Reason
A State Licensure survey was conducted at Magnolia Manor Methodist Nursing Center from December 5, 2023 through December 7, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including failure to comply with CMS regulations regarding physician visit frequency for one resident, inadequate infection control practices for respiratory equipment for two residents, and incomplete access to medical records for one resident, potentially hindering safe and effective care.
Deficiencies (3)
Failure to follow CMS regulations for frequency of physician visits for one of 124 residents (R118).
Failure to maintain infection control standard precautions by not keeping nebulizer mask and CPAP nasal cushions enclosed inside a bag when not in use for two of 18 residents (R99 and R112).
Failure to ensure one of 124 residents (R118) had complete access to the resident's medical record necessary for safe and effective care.
Report Facts
Residents affected: 1
Residents affected: 2
Total residents: 124
Residents with respiratory equipment issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dr FF | Medical Director | Named in deficiency related to physician visit frequency and medical record documentation |
| BB | Certified Nursing Assistant | Interviewed regarding respiratory equipment storage |
| AA | Licensed Practical Nurse | Interviewed regarding respiratory equipment storage |
| Administrator | Interviewed regarding physician delegation and medical record documentation | |
| Director of Nursing | Interviewed regarding respiratory equipment maintenance and infection control |
Inspection Report
Routine
Census: 124
Deficiencies: 5
Date: Dec 7, 2023
Visit Reason
A standard survey was conducted from December 5 through December 7, 2023, including investigation of three complaint intake numbers, two of which were substantiated with no citations.
Complaint Details
Complaint Intake Numbers GA00233315, GA00236647, and GA00240029 were investigated; GA00233315 was unsubstantiated, GA00236647 and GA00240029 were substantiated with no citations cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain resident dignity by leaving urinary catheter bags uncovered, failure to ensure timely physician visits, unsecured medication storage, incomplete resident medical records access, and inadequate infection control practices related to respiratory equipment.
Deficiencies (5)
Failure to maintain dignity and privacy of residents by leaving urinary catheter bags uncovered and visible from doorways.
Failure to follow CMS regulations regarding frequency of physician visits for residents, with one resident not seen or documented since admission.
Medication room door left unsecured and open ajar, allowing unauthorized access to medications and medical equipment.
Failure to ensure complete access to resident medical records, with physician and nurse practitioner notes not timely available in the electronic medical record.
Failure to maintain infection control by not keeping nebulizer mask and CPAP nasal cushions enclosed inside a bag when not in use for two residents.
Report Facts
Residents present: 124
Complaint intake numbers investigated: 3
Physician visit frequency requirement: 30
Physician visit frequency requirement: 60
Breathing treatments frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dr FF | Medical Director | Primary physician for all residents; failed to perform required routine visits and documentation |
| CNA GG | Certified Nursing Assistant | Stated urinary catheter drainage bags should be covered with privacy bag at all times |
| CNA HH | Certified Nursing Assistant | Confirmed catheter bags should be covered and not visible from doorway |
| CNA JJ | Certified Nursing Assistant | Confirmed catheter bags should be covered and not visible from doorway |
| CNA BB | Certified Nursing Assistant | Stated catheter bags should always be covered in privacy bag |
| LPN II | Licensed Practical Nurse | Confirmed catheter bags were uncovered and exposed to doorway |
| LPN AA | Licensed Practical Nurse | Stated residents with urinary catheters should have privacy cover on bag; stated nebulizer masks should be in a bag with resident's name and date when not in use |
| RN EE | Registered Nurse | Confirmed medication room door should remain locked and secured when authorized staff are not present |
| DON | Director of Nursing | Confirmed medication rooms and carts must remain locked; confirmed respiratory equipment must be covered when not in use |
Inspection Report
Life Safety
Census: 124
Capacity: 238
Deficiencies: 2
Date: Dec 5, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance due to missing escutcheon plates on sprinkler heads in room 530 and the use of an extension cord as permanent wiring in the conference room.
Deficiencies (2)
Failed to ensure that all escutcheon plates were attached to all sprinkler heads throughout the facility, specifically missing in room 530.
Failed to ensure all extension cords were removed from the facility; an extension cord was used as permanent wiring in the conference room.
Report Facts
Census: 124
Total Capacity: 238
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of missing escutcheon plate and extension cord usage during facility tour |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 07/17/2023 and 07/23/2023 as required by regulation, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Census: 120
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
A COVID-19 Focused Infection Control survey was conducted in conjunction with an Abbreviated Survey investigating complaint number GA00230134 from December 6, 2022 through December 8, 2022.
Complaint Details
Complaint number GA00230134 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and CMS/CDC recommended COVID-19 practices. The complaint was unsubstantiated and no regulatory violations were cited.
Report Facts
Census: 120
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 21, 2022
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags from the 8/2/2022 survey had been corrected.
Findings
The survey noted that all previously cited deficiencies from the prior survey had been corrected.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
The inspection was conducted from August 2, 2022 through August 4, 2022 to determine compliance with State Long Term Care Requirements.
Findings
No State Health Deficiencies were cited during the health survey.
Inspection Report
Routine
Census: 115
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
A standard survey was conducted at Magnolia Manor Methodist Nursing Center from August 2, 2022 through August 4, 2022. In addition, two complaint intake numbers were investigated with no deficiencies cited.
Complaint Details
Complaint Intake Number GA00224869 and GA00221367 were investigated with no deficiencies cited.
Findings
The standard survey revealed that the facility was in compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities. No deficiencies were cited during the complaint investigations.
Inspection Report
Life Safety
Census: 109
Capacity: 238
Deficiencies: 11
Date: Aug 2, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including missing or non-functional self-closing devices on doors, sprinkler system maintenance issues, missing escutcheon rings, unlabeled electrical panels, and failure of smoke doors and firewalls to close or seal properly.
Deficiencies (11)
Failed to install door closers on storage rooms 00121, 00122, 00123, and 00124.
Failed to repair door closer on unit 1 med room door.
Failed to remove items from sprinkler piping in dietary storage and unit 4 attic wires supported by sprinkler piping.
Failed to replace missing escutcheon rings in employee health 0022, common area unit 4, unit 4 nursing station, unit 4 room 437, and unit 6 nursing station.
Failed to green tag sprinkler system; Unit 1 sprinkler riser was yellow tagged while sprinkler company was working on system.
Failed to ensure corridor doors latch properly in multiple resident rooms and units.
Failed to remove louvered doors in main hall food pantry.
Failed to properly seal firewall penetrations in unit 4.
Failed to ensure smoke doors close properly in units 3, 4, 5, and 6.
Failed to remove power strips from the floor in multiple offices and nursing stations.
Failed to label electrical panel in dietary storage.
Report Facts
Census: 109
Total Capacity: 238
Smoke Compartments Affected: 6
Deficiencies Count: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour and observations |
Inspection Report
Deficiencies: 0
Date: Oct 28, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Magnolia Manor Methodist Nursing Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 120
Deficiencies: 0
Date: Oct 28, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 9/20/2021 complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 9/20/2021; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 9/20/2021 complaint survey were found to be corrected.
Report Facts
Census: 120
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 1
Date: Sep 20, 2021
Visit Reason
A Licensure Survey was conducted to investigate complaint intake numbers GA00214013 and GA00217625. The visit was initiated on 2021-09-16 and concluded on 2021-09-20.
Complaint Details
The investigation was initiated due to two complaint intake numbers GA00214013 and GA00217625. Complaint GA00214013 was substantiated without deficiencies. Complaint GA00217625 was substantiated with a deficiency related to inadequate heating.
Findings
The complaint GA00214013 was substantiated without deficiencies. Complaint intake GA00217625 was substantiated with a deficiency related to the facility's failure to maintain a comfortable interior temperature in rooms and a common area on the secure 400 unit, with temperatures observed between 64 and 70 degrees Fahrenheit and residents expressing feeling cold.
Deficiencies (1)
Facility failed to maintain a comfortable interior temperature in rooms and a common area on the secure 400 unit, with temperatures below the required 75 degrees Fahrenheit.
Report Facts
Residents observed: 15
Temperature readings: 69
Temperature readings: 70
Temperature readings: 68
Temperature readings: 64
Temperature readings: 67
Temperature readings: 68.5
Temperature readings: 68.5
Temperature readings: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding temperature controls and room temperature adjustments | |
| Administrator | Interviewed regarding air conditioner contractor contact and regulation requirements |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 9, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate a complaint (GA00211624).
Complaint Details
Complaint GA00211624 was investigated and found to be unsubstantiated.
Findings
The complaint investigation was concluded on the same day and was found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Census: 132
Deficiencies: 2
Date: Dec 2, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to have a qualified Infection Preventionist on staff and failing to properly document pneumococcal immunizations for residents as required by CDC guidelines.
Deficiencies (2)
Facility failed to ensure a qualified Infection Preventionist was on staff, lacking required training and part-time work at the facility.
Facility failed to follow CDC guidelines for pneumococcal vaccinations for two residents, lacking documentation of vaccine offer or refusal.
Report Facts
Census: 132
Residents reviewed for immunizations: 5
Residents with pneumococcal vaccine documentation issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named as responsible for infection control practices and interviewed regarding Infection Preventionist position and immunization documentation |
| Assistant Administrator | Assistant Administrator | Identified Infection Preventionist and confirmed lack of immunization documentation |
| MDS Coordinator | MDS Coordinator | Interviewed regarding lack of pneumococcal vaccine documentation for Resident 5 |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 16, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00209529.
Complaint Details
Complaint #GA00209529 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 15, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00202596, GA00203445, GA00204101, and GA00204424.
Complaint Details
Complaints #GA00202596, GA00203445, GA00204101, and GA00204424 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 133
Deficiencies: 0
Date: Jul 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Census: 159
Deficiencies: 0
Date: Sep 23, 2019
Visit Reason
A second Revisit survey was conducted on September 23, 2019, for the complaint survey originally conducted from June 3, 2019 through June 7, 2019.
Complaint Details
This was a revisit survey following a complaint survey conducted from 6/3/19 through 6/7/19. All prior deficiencies were corrected.
Findings
All deficiencies previously cited during the complaint survey were found to be corrected.
Report Facts
Facility census: 159
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 12, 2019
Visit Reason
A Revisit survey was conducted from 7/29/19 through 8/12/19 to investigate Complaint Intake Numbers GA00198320 and GA00198265. The visit was to assess continued compliance with Medicare/Medicaid regulations following substantiated complaints.
Complaint Details
Complaint GA00198265 was substantiated; Complaint GA00198320 was investigated in conjunction with the Revisit survey.
Findings
Complaint GA00198265 was substantiated, revealing continued noncompliance with Medicare/Medicaid regulations under 42 CFR Part 483, Subpart B for Long Term Care Facilities. Deficiencies were cited during the Revisit survey.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 12, 2019
Visit Reason
A revisit survey was conducted from 7/29/19 through 8/12/19, including investigation of two complaint intake numbers (GA00198320 and GA00198265), to determine compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Numbers GA00198320 and GA00198265 were investigated in conjunction with this revisit survey.
Findings
The facility failed to follow comprehensive care plans and physician orders for wound care for three residents (R#1, R#2, and R#6). Specific issues included failure to change dressings as ordered, use of another resident's medication, and failure to update treatment administration records to reflect new physician orders. These failures resulted in noncompliance with care plan and quality of care requirements.
Deficiencies (1)
Failure to follow care plan and physician orders for wound care for three residents, including not changing dressings daily as ordered and using another resident's medication.
Report Facts
Dates of wound care orders: Jul 25, 2019
Dates of wound care observation: Jul 29, 2019
Number of residents reviewed for wound care: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse EE | Named in findings for failing to transcribe physician orders and using another resident's medication | |
| Treatment Nurse DD | Observed wound care and confirmed dressing changes not performed as ordered | |
| Director of Nursing | Director of Nursing | Confirmed failure to follow physician orders and care plans |
| Administrator | Administrator | Confirmed failure to follow physician orders and care plans |
| Wound Care Physician | Wound MD | Provided wound care orders and confirmed miscommunication regarding wound care treatments |
| Nurse Practitioner | Nurse Practitioner | Typically signs off on wound care orders and confirmed no changes made to wound care recommendations |
Inspection Report
Routine
Deficiencies: 3
Date: Aug 12, 2019
Visit Reason
The inspection was conducted to evaluate compliance with nursing care plans and wound care treatment for residents, specifically reviewing adherence to physician orders and care plans related to wound care.
Findings
The facility failed to follow the care plan for three residents regarding wound care. Deficiencies included failure to change dressings as ordered, use of another resident's medication, and failure to update treatment administration records to reflect physician orders.
Deficiencies (3)
Failure to change wound dressing daily as ordered for Resident #1.
Use of another resident's medication (Santyl ointment) for Resident #2, not following physician orders.
Failure to update Treatment Administration Records for Resident #6 to reflect physician orders for daily Santyl wound care, resulting in continued use of Hydrogel three times a week instead of daily Santyl.
Report Facts
Residents reviewed for wound care: 6
Residents with care plan failures: 3
Dates of physician orders: Jul 25, 2019
Dates of physician orders: Jul 28, 2019
Dates of physician orders: Jun 20, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse EE | Interviewed regarding failure to transcribe physician orders and use of another resident's medication | |
| Treatment Nurse DD | Interviewed regarding wound care observations and failure to change dressing as ordered | |
| Director of Nursing | DON | Interviewed confirming that failure to follow physician orders equates to failure to follow care plans |
| Administrator | Interviewed confirming failure to transcribe physician orders and its impact on care plan adherence |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 18, 2019
Visit Reason
A Revisit Survey was conducted on 3/18/19 to verify correction of deficiencies cited during the standard survey on 1/25/19.
Findings
All deficiencies cited as a result of the standard survey of 1/25/19 were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 12, 2019
Visit Reason
A follow-up survey was conducted to verify correction of previously cited survey deficiencies.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 174
Capacity: 238
Deficiencies: 2
Date: Jan 22, 2019
Visit Reason
The Life Safety Code Survey was conducted to assess the facility's compliance with fire safety regulations under 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including improper installation of fire alarm notification devices in Unit 6 and unprotected corridor openings in Unit 3 doors, potentially placing residents at risk in the event of a fire.
Deficiencies (2)
Fire alarm notification devices (horn strobes) in Unit 6 were mounted greater than 96 inches above the finished floor, not in accordance with NFPA 72.
Corridor openings in doors to Unit 3 laundry and Unit 3 floor pantry had louvers, failing to protect corridor openings as required.
Report Facts
Residents at risk due to fire alarm deficiency: 28
Residents at risk due to corridor opening deficiency: 25
Census: 174
Total licensed capacity: 238
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire alarm device mounting and corridor door louvers during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 26, 2018
Visit Reason
An abbreviated/Partial Extended Survey was conducted to investigate complaint GA00193523.
Complaint Details
Complaint GA00193523 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 3, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00191469, GA00191599, and GA00191643.
Complaint Details
The complaints GA00191469, GA00191599, and GA00191643 were investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaints investigated during the survey were unsubstantiated and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 8, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00190368 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00190368 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted on 8/7/18 through 8/8/18.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 12, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00189143.
Complaint Details
Complaint GA00189143 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 10, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00187300.
Complaint Details
Complaint #GA00187300 was investigated and found to be unsubstantiated.
Findings
The complaint investigation was unsubstantiated with no deficiencies noted in the report.
Inspection Report
Re-Inspection
Census: 173
Deficiencies: 0
Date: Mar 30, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the February 1, 2018 standard survey.
Findings
All deficiencies cited in the prior February 1, 2018 standard survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 20, 2018
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as of the follow-up survey date.
Inspection Report
Life Safety
Census: 172
Capacity: 238
Deficiencies: 2
Date: Jan 29, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with smoking regulations as required by NFPA 101 2012 edition. Specifically, the employee smoking area lacked a metal container with a self-closing lid for cigarette butts, and the facility smoking policy did not designate an employee smoking area with required provisions.
Deficiencies (2)
Employee smoking area located at the rear loading dock did not have a metal can with a self-closing lid for cigarette butts.
Facility smoking policy failed to designate an employee smoking area with required provisions.
Report Facts
Census: 172
Certified Beds: 238
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 20, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00182052.
Complaint Details
Complaint GA00182052 was investigated and found to be unsubstantiated.
Findings
The complaint investigated during the survey was found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 15, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate GA00179299 on 9/15/2017.
Findings
The survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B. No deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 22, 2017
Visit Reason
A follow-up inspection was conducted to verify correction of deficiencies identified during the standard survey on 2017-01-26.
Findings
The deficiencies identified in the standard survey of 1/26/17 were corrected as of the follow-up visit on 3/22/17.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 16, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey deficiencies had been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 2, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaint #GA00172178 and determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
Complaint #GA00172178 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Census: 181
Deficiencies: 1
Date: Jan 26, 2017
Visit Reason
A standard survey was conducted in conjunction with complaint # GA00169563 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint # GA00169563 triggered the survey. The deficiency related to failure to revise the plan of care was substantiated based on staff interview and record review.
Findings
The facility failed to revise a resident's plan of care to include a stage two pressure ulcer to the left elbow for one resident (#194) from a sample of 22 residents. The plan of care was not updated until after surveyor inquiry.
Deficiencies (1)
Failure to revise plan of care to include a stage two pressure ulcer for resident #194.
Report Facts
Resident census: 181
Resident sample size: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Confirmed resident had a stage two pressure ulcer. | |
| Registered Nurse (RN) BB | Confirmed plan of care had not been revised and stated it was an oversight. |
Inspection Report
Life Safety
Census: 181
Capacity: 238
Deficiencies: 5
Date: Jan 23, 2017
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including issues with egress door locking arrangements on the memory care unit, overdue UL 300 fire suppression system inspection, lack of sprinkler coverage in resident room closets, corridor doors with improper locking mechanisms, and smoke barriers lacking required fire resistance rating.
Deficiencies (5)
Failed to provide approved locking arrangements on egress doors to meet clinical needs of the memory care unit, with more than one locking device on each of the 3 corridor egress doors from unit 4.
Failed to maintain the UL 300 fire suppression system in accordance with NFPA 96; system was past due for semi-annual inspection (last inspected 04/03/2016).
Failed to provide an approved sprinkler system in accordance with NFPA 13; all 60 of the unit 5 resident room closets were not sprinkled.
Failed to provide door openings to the corridor suitable for keeping the door closed and acceptable to the authority having jurisdiction; 5 supply closets and 5 storage closets had padlocks or sliding hasp locks on the exterior side of the door.
Failed to provide smoke barriers with at least a one half hour fire resistance rating; smoke barrier wall above the door protecting the 40 wing in unit 5 was not sealed at the deck with approved fire stop material.
Report Facts
Residents at risk due to egress door locking deficiency: 29
Residents at risk due to sprinkler system deficiency: 22
Residents at risk due to sprinkler system deficiency: 181
Certified beds: 238
Census: 181
Number of resident room closets not sprinkled: 60
Number of supply closets and storage closets with improper locks: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during the inspection including door locking deficiencies, fire suppression system status, sprinkler system deficiencies, corridor door issues, and smoke barrier deficiencies. |
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